AIDS in South Africa: biology, culture, and disease

AIDS in South Africa

Those of us living in the United States became used to the face of AIDS a generation ago. We learned to recognize the particular gauntness that characterized those who had been struck by it, and who would soon be taken away by it. And then, after years of people dying from this disease, we learned that people who had this terrible disease could be healed; not cured, for they still contained the viruses within their bodies, but they could live lives that were happy and meaningful - and long. The terror of AIDS subsided, becoming one of only many of the perils of modern life rather than one of the predominant ones.

But the trajectory of AIDS in South Africa (as well as in other parts of the developing world, has been very different. Even in the first years of the disease the manifestations of it tended to be worse in Africa, and the gap between Africa and the United States and Europe has only grown in the generation since, as Bond (1997) argues. This paper examines the impact that AIDS has had on South Africa, an impact that is based in the biology of the disease itself but far more in the social, cultural and economic conditions of this region of the world. For disease is never a purely physical phenomenon: The ways in we understand illness - and the ways in which we seek to combat it - are always a function of culture and belief, of economic resources, of history (Garrett 19).

The struggle against AIDS in South Africa reminds us of the cultural bases of both disease and health - and even more about how the practice of Western medicine is as culture (and so as rule-governed) as other systems of belief. This refutes the commonsense attitude that many readers might bring to the book, which dictates that the concepts of health and illness seem at first glance to be entirely biological constructs. After all, a person contracts tuberculosis not because she belongs to a certain religion or because he is a certain ethnicity but because a particular type of bacillus enters into her or his body and infects its human host. People get epilepsy because of a particular mis-wiring in their brains. Nothing could seem more straightforwardly objective and clear-cut and scientific. But in fact the picture is more complicated than this.

Health (and the absence of health, or sickness) is culturally constructed. Both concepts of sickness and perhaps even more ideas about health are in fact deeply culturally rooted in the specific belief systems of a given role and society. We get sick for a number of reasons - and through the invasion of our bodies by a number of parasites. This is as close to an objective Truth as any of us is likely to get. But health, and sickness (and what to do about either) is not only a matter of objective truth; belief matters at least as much as truth. It is impossible to understand the impact of AIDS in South Africa without remembering this, or without acknowledging this.

Part of understanding AIDS in South Africa (at least for those of us who are from other places in the world) is an understanding of traditional African beliefs - such as the fact that witchcraft is known by many Africans to cause unfortunate things to happen. This may be because witches themselves are evil and untrustworthy. Or it may be that the person involved has in fact done something bad and deserves to be cursed.

In order to understand something more of the cosmology of traditional Africans (and bearing in mind that we must treat their beliefs with as much respect as we do our own) let us sketch a hypothetical situation involving witchcraft. Let us assume that there is someone known to be greedy, selfish, and violent. One day this person becomes gravely ill after eating a newly discovered kind of berry. Everyone in the village comes to the conclusion that a) witchcraft exists; b) witches curse bad people; c) person X is a bad person; therefore d) a witch has placed a curse on this new fruit to teach person X not to be such a bad person anyone or at least to punish him.

Well that's silly, we are all tempted to say. Curses don't cause illness. Toxins and microbes do.

Well, possibly. But let us look at the syllogism that Westerner might invoke in the same situation. a) Toxins and microbes exist; b) toxins and microbes hurt people; c) person X is a person and so can be hurt; therefore d) person X has eaten a fruit that is either poisonous or infectious.

But you may say that the two cases are entirely different, that poisons are real, for example, and curses are not. There are two rejoinders to this. Certainly most Americans believe that in fact poisons are real. But, on the other hand, most of them have no personal expertise in detecting them as I am not a chemist. If someone points out a fruit to most people and tells them that it is poisonous, they have to take this on faith.

There is no significant difference between a person's accepting that a particular fruit is poisonous just because the person who says so has an advanced degree in chemistry and a villager learning about curses from an elder. Both systems of thought require that lay people - whether non-scientists or non-witches, take a great deal on faith from experts.

The mixture of traditional understanding of cause and effect (such as in our hypothetical case above) with Western medical concepts is part of the story of AIDS in South Africa - along with the political and economic situation of the country. All of these will be explored in greater detail below.

The importance of designing and instituting an effective AIDS prevention program in South Africa is imperative because of the number of people already sick with the disease, its probably spread, and the terrible costs to South African society that will result from the pandemic unless significant social intervention occurs. South Africa has more HIV-positive people than there are in any country in the world. The following statistics give us some sense of how terrible the pandemic could (and in fact is likely to) become in South Africa:

Estimated HIV Infected: 4.8 million

Estimated 1999 AIDS Deaths: 250,000

Estimated AIDS Orphans: 420,000

11% of South Africans are HIV-infected; by 2010 adult HIV prevalence could reach 25%.

Daily estimates of 1,600 people with new HIV infection; two-thirds of them aged 15 to 20.

By 2008, 1.6 million children will have been orphaned by AIDS.

South Africa has a well-developed health infrastructure relative to other African nations, and there is a substantial amount of international and donor interest in the country.

In 2005 the population is expected to be 16% lower than it would have been in the absence of AIDS. By 2015 population loss to AIDS-related deaths will be 4.4 million.

In 1998 South Africa had approximately 100,000 AIDS orphans, and by 2008, 1.6 million children will have been orphaned by AIDS.

An estimated 50% of all tuberculosis patients are co-infected with HIV. In some hospitals in South Africa, the HIV prevalence in tuberculosis patients is higher than 70% (http://www.cdc.gov/nchstp/od/gap/countries/south_africa.htm).

The figures above give a good sense of the seriousness of the disease in South Africa in medical terms. However, even these figures fail to convey the true cost that South Africa will have to bear over the next generation as a result of the pandemic:

HIV / AIDS will create significant economic costs to businesses, although the long-term macro-economic impact is likely to be limited to a Gross Domestic Product (GDP) growth rate reduction of about 1% per annum (http://www.aids.org.za/,Lamont 2002)

HIV / AIDS care will become a substantial part of health care spending, thus substantially limiting the ability of the country to pay for other vital health services, including especially the prevention and treatment of tuberculosis and maternity care (http://www.aids.org.za/).

South African women, who already perform more than half of the work of the nation (http://www.aids.org.za/,Nessman 2002; Khan 2003)

The HIV epidemic will produce large numbers of AIDS orphans (by 2005 there will be nearly a million children under the age of 15 who will have lost their mothers to AIDS) (http://www.aids.org.za/)

Education will be affected through staff becoming infected and through increasing needs of affected and infected children. The need to educate children, in addition to becoming more pragmatically difficult, may well seem to be less important to a nation that feels that its future has been fundamentally compromised (McGreal 2002; "AIDS against AIDS" 2003).

The ability of the nation's welfare system to help those debilitated by AIDS, AIDS orphans the elderly who no longer have adult children to care for them will be severely tested; in the likely event that the government is unable to provide needed social services the nation's citizens are likely to lose faith in their government (http://www.aids.org.za/)

The majority of South Africans will be affected by this epidemic everyone in the nation is likely to know someone among their family members, friends and colleagues who is sick with the disease. Many may well lose any sense that there can ever be a world in which AIDS is defeated (Cohen 2002; Bennett 2002)

Social and political instability may increase as families and whole communities break down and people's belief in post-colonial governance systems fails (http://www.aids.org.za/)

Background of the AIDS Pandemic

Having just argued that AIDS (like other diseases) is as much a cultural and economic phenomenon as a physical one, we will nonetheless begin here with a primer on the biology of the disease. AIDS - the acronym for Acquired Immune Deficiency Syndrome, the name by which it is almost never called anymore - is a disease that destroys the ability of the human immune system to fight off invasions by the variety of microorganisms that are constantly around us. This is the basic biological basis of a disease that has usually been defined more in behavioral and moral terms in the West than in epidemiological or medical ones: The fact that most early AIDS sufferers in the West were gay men and IV drug-users had an immense effect on how the drug was characterized.

The most common means of transmission of AIDS in South Africa has been heterosexual sex (followed by mothers passing the disease to their children in utero, during birth or by nursing; nevertheless, some of the stigma that attached to the disease because of means of transmission in the West also attached to potential Western aid to African AIDS at least initially. This was certainly compounded by racist attitudes that dismissed the importance of the death of Africans (viz. Holmes 2002; Guest 2001; and Shoumatoff, 1990).

Although AIDS can vary quite dramatically from patient to patient (since the symptoms that people exhibit are due in large measure to the specific combination of opportunistic infections that that person is afflicted with), there are general physical symptoms associated with most cases, including dramatic weight loss and fatigue. Many of those with the disease suffer some form of neurological complication that is caused by damage to brain structures.

A number of specific diseases are associated with AIDS - including a number of kinds of cancer, including Kaposi's sarcoma and B-cell lymphomas. These are not present in all cases of AIDS, however, and are generally found in those who live with the disease for a longer period of time, which is more common of those suffering from AIDS in the West than in Africa.

AIDS is not causally contracted but is instead transmitted through intimate sexual contact, through infected blood and from infected mothers to their babies. In the early days of the pandemic, a major sources of transmission was contaminated blood given in transfusions; this is no longer the case in the First World.

One of the major reasons that the disease has been able to spread so dramatically is that fact that it has such a long period of dormancy: People can be infected for up to 10 years before they begin to feel sick, which gives them years to infect their sexual partners, children, or IV-drug needle sharers without knowing it (http://www.pbs.org/newshour/bb/health/july-dec98/aids_12-2/html).The lethalness of the long dormancy period is somewhat less evident in Africa where there tends to be a shorter period of time (than in the United States or in Europe) between infection and symptoms.

Alternative" AIDS Theories

While AIDS exports world-wide agree with Geshekter that these are indeed the factors that have contributed to the spread of AIDS in Africa and to the difficulties of treating the disease in South Africa. However there are alternative models of the disease that have come out of Africa itself. These models, which question whether there is in fact any causative link between the presence of HIV in a person's body and that person's having AIDS, are dismissed by the reputable scientific community. However, they clearly have an important cultural validity to them; it is striking that similar anti-HIV models circulated in the United States amongst some gay activist groups.

Traditional explanations of disease, such as witchcraft, also inform such questioning of established biomedical models.

Both South Africans and gay American men are socially marginalized (within the context of the hierarchy of the world system). Socially disenfranchised groups (and especially socially stigmatized groups, a characterization that is more true of gay men than of black South Africans, but is still true of both) are often targeted by those in power. This reality of human society has tended in many cases to make those out of power suspicious of the conventional explanations for events that adversely affect those minority populations (Spitzer 1993).

This is no doubt one of the reasons behind (for example) South African President Thabo Mbeki's very public questioning of whether HIV does in fact cause AIDS (Baleta 2002a, Baleta 2002b; Baleta 2002c). In some ways his questioning made sense given the uneven ways in which AIDS is distributed across the globe:

After months of deliberations and internal strife, Mbeki and the government of South Africa convened a two-day panel in Pretoria, May 6-7, at which 33 scientists deliberated about the evidence for and against HIV as the single and sufficient cause of AIDS worldwide. They also discussed the drugs used to combat it, and asked themselves whether the drugs have saved lives or ended lives. The AIDS orthodoxy was widely quoted as fuming about Mbeki wasting time on dead scientific questions while they themselves were busy saving lives (http://www.virusmyth.net/aids/data/cfmbeki.htm).

War By Other Means

Not all wars are fought with guns, and not all enemies are visible. South Africa must (and in many ways is) fight AIDS as if it were an invading army. This is of course difficult to do: AIDS is a sort of terrorist force attacking the South African population: It presents no obvious target to aim against. But simply because it is a difficult enemy to fight does not mean that it is not essential for the nation and its people to marshal all of their forces against it:

In January 2000, The United Nations' Security Council debated on the impact of AIDS on peace and security in Africa. The debate was the first in the Council's history that discussed a health issue as a threat to peace and security. UN secretary-general Kofi Annan told the council: 'The impact of AIDS in Africa was no less destructive than war itself. By overwhelming the continent's health workers and teachers, AIDS is causing social and economic crises which in turn threaten political stability.

In already unstable societies, this cocktail of disasters is a sure recipe for more conflict. And conflict, in turn, provides fertile ground for further infections (http://www.nkosi.iafrica.com/aids_sa/).

AIDS is both the enemy in South Africa and a potential aid to other enemies. One of the reasons that AIDS has been successfully fought in the United States and Europe is the wealth of these nations; this has certainly been their primary advantage. But they have also benefited in the fight against AIDS from a high degree of social stability; public health measures can only be effective when used in a stable society.

One of the terrible ironies of AIDS in South Africa is that the nation does not have strong enough social structures to allow (at least so far) for the necessary public health measures to be taken. And as AIDS takes a greater and greater toll, the necessary social structures will only become weaker and weaker.